What is the treatment for superior sagittal sinus thrombosis?

Treatment of Superior Sagittal Sinus Thrombosis

In patients with superior sagittal sinus thrombosis, anticoagulation therapy is strongly recommended for at least the first 3 months (treatment phase) over no anticoagulant therapy. 1

Initial Management

• Begin therapeutic anticoagulation immediately upon diagnosis, even in the presence of intracranial hemorrhage, as the benefits of preventing thrombus progression outweigh bleeding risks 1, 2
• Low molecular weight heparin (LMWH) or unfractionated heparin (UFH) are the preferred initial treatment options 1, 2
• Delaying anticoagulation due to fear of hemorrhagic complications can lead to thrombus progression and worse outcomes 2

Anticoagulation Options and Duration

• For the initial treatment phase, LMWH is preferred over vitamin K antagonists 2
• After initial therapy, transition to adjusted-dose vitamin K antagonists (target INR 2.5) for the remainder of the treatment phase 2
• Direct oral anticoagulants (DOACs) are not currently recommended as first-line therapy for cerebral venous thrombosis due to limited evidence 2
• Continue anticoagulation for at least 3 months (treatment phase) 1

Management of Complications

Increased Intracranial Pressure

• Monitor for signs of increased intracranial pressure which may require additional interventions such as osmotic therapy (mannitol or hypertonic saline) 2
• In cases of deterioration despite medical therapy, surgical decompression with hematoma evacuation may be necessary 2, 3

Hemorrhagic Complications

• Even in patients who develop intracranial hemorrhage, anticoagulation should generally be continued as the risk of thrombus progression often outweighs bleeding risks 1, 2
• In severe hemorrhagic complications, temporary discontinuation of anticoagulation may be necessary, but should be resumed once the patient is stabilized 2

Monitoring and Follow-up

• Regular neurological assessment is essential to detect early signs of deterioration 2
• Follow-up imaging (MRV or CTV) should be performed to assess recanalization 2
• Monitor for signs of pulmonary embolism, which is a potentially fatal complication of superior sagittal sinus thrombosis 4

Special Considerations

• Patients with sudden onset of symptoms (<24 hours) and posterior 1/3 occlusion of the superior sagittal sinus may have worse outcomes and require more aggressive management 5
• Early diagnosis and treatment are crucial, as superior sagittal sinus thrombosis can be potentially fatal if left untreated 4, 3
• Consider underlying causes such as hypercoagulable states, malignancy, or postpartum state that may require additional specific management 3, 6

Treatment Algorithm

1. Confirm diagnosis with MRI/MRV or CT/CTV 2
2. Initiate therapeutic anticoagulation immediately with LMWH or UFH 1, 2
3. Monitor for neurological deterioration and signs of increased intracranial pressure 2
4. Transition to vitamin K antagonists after initial stabilization 2
5. Continue anticoagulation for at least 3 months 1
6. Perform follow-up imaging to assess recanalization 2

Pitfalls to Avoid

• Delaying anticoagulation due to fear of hemorrhagic complications 2
• Misdiagnosing headache as migraine, leading to delayed treatment 2
• Using DOACs as first-line therapy without sufficient evidence 2
• Failing to monitor for pulmonary embolism, which is a potentially fatal complication 4